LSUS MHA 707 Exam D with 100% correct answers already graded A+

Opening of 20th Century

· Drs were solo practitioners

· Hospitals were single, independent entities, mostly non-profit

· Long-term care for the elderly was largely home-based

· Pharmaceuticals & medical device manufacturing was a small business

· Healthcare was a minor part of economy

Founding of American Medical Association (AMA)

1847

American Medical Association (AMA)

· Established standards for preliminary medical education for the degree of MD

· Code of Medical Ethics

· Recommended use of anesthetic agents for surgery/obstetrics

· Noted dangers of secret remedies (snake oil) & patent medicines

· Recommended state govs register births, marriages, & deaths

Advances making practice of med more successful in treating health problems

· Improvements in surgery made during Civil War (toilets downstream from Army's campsite)

· Application to medicine advances in bacteriology by scientists such as Louis Pasteur (ability to control infections - leading cause of death at the time)

Demand for therapeutics fueled by Civil War

· Provided start for some of largest names in modern pharma industry: Wyeth, Pfizer, Squibb

Found of U.S. Nursing Corps (professional nursing)

1861 (19th century)

Development of Ambulance Corps during Civil War

· Created ambulance-to-ER system we know today

· Estab. Hierarchy of tx stations to type of hospital facilities

Association of Hospital Superintendents became

· American Hospital Association (AHA)

Founding of Association of Hospital Superintendents

1899

Adoption of the Bertillon or International List of Causes of Death

1900

Bertillon or International List of Causes of Death

· Predecessor of International Classification of Diseases (ICD)

· Brought some standards & criteria in the study of diseases

Both public & private sectors were involved in

· Providing health care coverage

· Building the American health care infrastructure

Access to health care for members of military, vets, & family had become a public sector initiative

1811

1910

· Early forerunners of health insurance plans appeared as "prepaid" group practices

· Plan members paid monthly premium & received a wide range of medical services throughout exclusive group of providers

1929

· BC plans were established to provide "prepaid" hospital care to workers in Dallas Public School system

· Created by Baylor

BCBS developed nationwide due to

· U.S. entering WW2 w/ caps on wages

BCBS unified

1940s

BCBS together served

· 24M, 81 hospital plans, 44 med plans

By 1960s BC had

· 52M

By 1960s BS had

· 40M

BCBS covered what percent Fed employees

· 33%

BCBS offered by

· Voluntary, nonprofit companies

· Estab. As charitable & benevolent organizations

BCBS used what to set prices for their products

· Community Rating

Why did BCBS use Community Rating?

· Data too poor to do anything else

Community Rating refers to

· Insurance pricing whereby everyone in same geographic area pays same premium

· Regardless of health status, age, gender, family composition, occupation, health behaviors such as smoking, or claims hx

Experience Rating

· Tailors policies & premiums to particular group or individual

· Premiums based on person's claims, health status, & risk of future claims as indicated by their age, gender, health behaviors, & so forth

Congress passed legislation for 3 groups not covered by employer-based insurance

· Medicare (65+)

· Medicaid (uninsured, low-income)

· CHIP (uninsured, moderate income)

· Between 1965 - 1999

2 Fed health policies enacted to solve problems related to health care coverage

· EMTALA

· HIPAA

· 1986

Emergency Medical Treatment & Labor Act (EMTALA)

· Prohibited "dumping" by Medicare participating hospitals w/ active ERs

Health Insurance Portability & Accountability Act (HIPAA)

· 1996

· Brought about # of significant improvements in access to health coverage by mandating

o Continuity or "portability" of coverage in private health insurance markets

o Health insurance coverage for @least 2-day hospital stay for women who gave birth vaginally & 4 days for C section deliveries

o Sponsored by Texas senator Phil Gramm

o Mental health was given same status a physical health by HIPAA legislation

HIPPA & Privacy

· Data w/in med rec belongs to pt.

· Pts have right to ensure info contained in rec is accurate

· Pts can petition provider to change incorrect info

Hospital developed as heart of HC delivery system

20th century

Community hospitals built with

· Fed funds through Hill-Burton Act

Voluntary, nonprofit hospitals built by

· Private Sector

Hospital built by

· Military for members, vets, & family

Public hospitals built by

· Gov entities for poor (usually local gov)

1900-1930

· 0.3% of Growth Domestic Product (GDP)

1960

· 1.3% GDP = 4x, four-fold, 400%

1980

· 4.1% GDP = 3x since 1960, 13.6x since 1930

Incremental Changes

· Expansion of capitation & rise of managed care

· Growth of vertical & horizontal integration of HC orgs & integrated delivery systems

· Increase in for-profit HC orgs

2 contrasting ways to pay HC providers for services

· Capitation

· Indemnity Health Insurance (difference is in who takes risk)

Capitation

· Practice of paying flat fee to HC provider in exchange of services during given time period, usually 1 year

· Flat fee guarantees medical coverage for the person regardless of how much/little care the individual needs/uses

Indemnity Health Insurance

· Reimburses individual for fees paid for med services after they are performed

· Payment may be made to pt or directly to provider, on retrospective, fee-for-service basis

· Providers not employed by, contracted to , or owned by payer (insurer)

· Insurer simply pays for care according to agreed-to schedule

· Financial responsibility (or risk) for cost of HC born by insurer

· Beneficiaries (most cases, the beneficiaries' employer) pay sums (usually premiums) to insurance companies

· In turn, insurance companies pay providers for care used by beneficiaries

· Payment made on fee-for-service or item-of-service basis, after service is receive (or retrospectively)

· Usually some out-of-pocket (deductibles/coinsurance) paid by beneficiaries, & dollar-amount limits on services covered by insurance

What increase with organization change?

· Capitation

Organizational Change

· From solo physician practices financed primarily by indemnity insurance to group practices financed primarily by capitation

Organizational changes began with

· Development of prepaid group medical practices, later with health maintenance organizations (HMOs), then with managed care organizations (MCOs)

Value Equation

· Value = Quality / Cost

Value Equation (modified)

· Value = Outcome (quality, efficacy, safety) / Cost (resource tallies, dollars)

Multi-unit hospital systems

· Include 2+ acute-care hospitals owned, leased, or managed by a single corporate entity

· # & size will continue to increase

Private sector health care organizations were predominantly nonprofit

· 1st half of 20th century

Mid century

· BCBS largest private health insurer, & all its affiliates were obligated to adhere to a voluntary nonprofit status

· Most, if not all, private hospitals were also involuntary, nonprofit organizations

Early 1900s

· Profit making had clear foothold (ex. BCBS association's decision in 1994 to permit its affiliates to switch to for-profit status)

The question is not moral but functional

· "Can a profit-making system & the free market solve the myriad of problems of the U.S. HC system?"

· Dr. Bost = Drs becoming employees having to follow protocols & formularies

Reform until 1990s were related to achieving

· National Health Insurance (NHI)

Proposals to create an NHI have been on the national political agenda in U.S. since

1912

Teddy Roosevelt & Bull Moose party (election 1912)

· Plank was NHI

NHI programs may be administered by

· Gov (fed/state), private sector, combo

NHI programs usually estab by

· Fed legislation

NHI financed through

· Taxation, private sector (employers), or individual contributions (OOP $, union dues, etc.), combo

1st NHI programs appeared in

1880s

1st NHI program introduced by

· Otto von Bismarck, the "Iron Chancellor" of Prussia

Bismarck succeed in passing a Sickness Insurance Act

· 1883

Opposition to Bismarck's plan led to system with

· Both for-profit & nonprofit societies

Program provided cash support during periods of sickness & accidental injury

· Bismark's plan

Fraction of premiums paid by employees

· 2/3

Fraction of premiums paid by employers

· 1/3

1st NHI created by a

· Conservative constitutional monarchy

Most of European industrialized countries, as well as Japan, had some kind of NHI system

· By 1920s

How did NHI system begin

· As a partial or voluntary system, generally progressing to a comprehensive & compulsory

Many universal health systems were formed to

· Placate workers who were being courted by socialist/communistic movements

1st campaign (for NHI in U.S.) undertaken by

· The American Association for Labor Legislation (AALL)

AALL

· Middle class, liberal reform minded group founded in 1906

1916

· AALL proposed compulsory medical care & sickness benefits insurance that would have:

o Covered persons earning below a certain income level (poor)

o Used existing insurance carriers

o Shared costs among employers, employees, & states

o Been adopted by each state independently [some would, some wouldn't]

At 1st support was widespread, extending to the

· AMA & even the National Association of Manufacturers

Beginning in 1917, why did U.S. entry into WW1 generally deflate the reform movement?

· NO $$$

There was opposition from the

· American Federation of Labor Commercial Insurance Industry

The conservative practitioner faction won the

· Overall shift of power from academic wing of medical profession to practitioner wing

1920

· The AMA house of delegates passed a resolution opposing (NHI)

1990

· AMA dropped the non-compulsory principle

Serious consideration was next given to NHI during the development of

· The Social Security Act of 1935

. The Committee on the Costs of Medical Care (CCMC) in 1932 was stimulated in part by the final report

1934

· President Franklin Roosevelt created the committee on economic security to consider the whole question of social insurance

· NHI was on the agenda BUT did not stay on it long

NHI in U.S.: new deal & post-war proposals came with principal opposition, again coming from

· The AMA

President Roosevelt wanted to ensure the basic Social Security Act, a cornerstone of New Deal, became a law which was

· Eventually passed by Congress with no reference to NHI

Senator Robert Wagner, Sr. (D-New York) initiated

· The next major legislature for comprehensive reform including NHI in 1939 bill (S-1620) which would have provided for

o Public health/prevention & control of disease

o Maternal & child health services

o Construction & maintenance of needed hospitals & health centers

o Care of the sick & disability insurance

o Training of personnel

o Tried again (1943) with Senator James Murray (D-Montana) & Representative John Dingell (D-Michigan)

Who vigorously opposed the death of Bill S-1620 in committee

· AMA

Senators Robert Wagoner & James Murray, & Representative John Dingell's Bill (S-1161) advocated for

· A national (federal) compulsory system of health insurance, financed from payroll taxes & providing comprehensive health & medical benefits through entitlement to specific medical service benefits

Bill S-1620

· 1st major legislative proposal for a federal rather than a state-based system

· AMA oppose & bill was defeated

1949

· Harry Truman re-elected w/ Democratic majorities in both houses of Congress

Major goal of Truman's administration

· Enactment of NHI

Similar Wagner-Wagner-Dingell bill (1943), Truman proposed a national, compulsory system to be paid by

· a combo of Social Security & general taxation

Truman argued

· Everyone should have ready access

· A system of required payment that would help prevent much serious disease

· A system of prepayment to cover medical, hospital, nursing, & lab services & dental, if possible

Truman was NOT proposing socialized medicine

· "Socialized medicine means all doctors work as employees of gov...no such system is proposed."

Truman proposal would have/be

· Maintained mix public/private sector involvement & appealed to American preferences of choice

· Nation-wide system must be highly decentralized in administration

· Subject to national standards, but methods & rates of paying Drs & hospitals should be adjusted locally

· People should remain free to choose their own physicians/hospitals

· Physicians should remain free to accept/reject pts

· Voluntary, city, country, & state general hospitals should be free to participate in the system to whatever extent they wished

Why did the AMA attack Truman's plan?

· Primarily claimed the plan was indeed "socialized medicine"

AMA had allies in

· Drug & insurance industries

1951

· Truman administration withdrew support for the NHI proposal

1965

· Truman began the campaign that eventually led to passage of Medicare

As of 1975, there were

4 major proposals before Congress

After the passage of Medicare & Medicaid, many new legislative proposals for NHI were made. Constituencies represented were

· Organized labor

· American Hospital Association (AHA)

· Health Insurance Association of America (HIAA)

· AMA

· NONE WERE PASSED!

The last of the comprehensive health care reform proposals of the 20th century

· The Health Security Act (Clinton Admin)

Groundswell of concern (1980s-1990s)

· Escalating health care costs

· Growing # of uninsured

· Declining health for certain populations

Proponents of Reform included:

· Sen. Ted Kennedy's Committee on Labor & Human Resources (1988)

· National Association of Manufacturers (1989), Heritage Foundation (1989)

· National Leadership Commission of Health Care - Co-chaired by former presidents Richard Nixon, Gerald Ford, & Jimmy Carter (1989)

· Oil, chemical, & atomic workers (1989)

· Committee for National Health Insurance (affiliated with the AFL-CIO (1989)

· AMA (1990), American Public Health Association

· U. S. Bipartisan Commission on Comprehensive Health Care of the U.S. Congress

· Physicians for a National Health Program's "Single-Payor" system